Presentation is loading. Please wait.

Presentation is loading. Please wait.

End-Stage Heart Failure: Surgical Options ischemia (CABG) mitralis insuf. (RMA) "Dor" aneurysmectomy Surgical Ventricular Restoration mechanical /assistance.

Similar presentations


Presentation on theme: "End-Stage Heart Failure: Surgical Options ischemia (CABG) mitralis insuf. (RMA) "Dor" aneurysmectomy Surgical Ventricular Restoration mechanical /assistance."— Presentation transcript:

1

2 End-Stage Heart Failure: Surgical Options ischemia (CABG) mitralis insuf. (RMA) "Dor" aneurysmectomy Surgical Ventricular Restoration mechanical /assistance replacement HTX REPAIR RESHAPE REPLACE

3 Systolic restrictive motion

4 > 30 > 0.2 IMR RV (ml) > 60 ERO (cm 2 ) > 0.4ORGANIC ECHO CRITERIA OF SEVERE MR M. Enriquez-Sarano

5 Restrictive Mitral Annuloplasty: two sizes under

6

7 Postoperative echo result

8 Restrictive Annuloplasty for Ischaemic Mitral Regurgitation results in Reverse Left Ventricular Remodeling J. Braun, J.J. Bax, M.I.M. Versteegh, P.G. Voigt, E.R. Holman, R.J.M. Klautz, R.A.E. Dion Departments of Cardiothoracic Surgery and Cardiology, Leids Universitair Medisch Centrum

9 Patient characteristics EACTS 15/09/04 Jan 2000 – March patients age 66 ± 10 yrs NYHA 3.0 ± 0.9 III / IV: 82 % log EuroSCORE11.0 ± 10.8 previous CABG7 %

10 Baseline echocardiography MR grade3.1 ± / 4+ : 81 % LA size (mm)54 ± 6 LVESD (mm)52 ± 8 LVEDD (mm)64 ± 8 LVEF (%)32 ± 10 EACTS 15/09/04

11 Surgery median annuloplasty ring size26 CABG86 % mean distal anastomoses3.3 ± 1.3 CPB time (min)189 ± 52 Ao-clamp (min)125 ± 37 EACTS 15/09/04

12 Results (1) Time (years) Cumulative Survival 1,0,9,8,7,6,5,4,3,2,1 0,0 Early mortality 8.0 % (n=7) Late mortality 7.5 % (n=6)

13 Results (3) Baseline3.1 ± 0.5 Coaptation height 8 ± 1 mm MV diastolic gradient 2.4 ± 0.6 mmHg EACTS 15/09/04 Mitral regurgitation Early 0.4 ± 0.3 Late 0.6 ± 0.6

14 Results (4) LVESD (mm) Baseline52 ± 8 Late FU 44 ± 11 EarlyLateNo reverse remodeling 40% 33% 27% (p < 0.01)

15 Results (5) LVEDD (mm) Baseline64 ± 8 Late FU 58 ± 10 EACTS 15/09/04 42% 22% 36% EarlyLate No reverse remodeling (p < 0.01)

16 LVESD and Reverse Remodeling LVESD (mm) specificity sensitivity 81 % 51 EACTS 15/09/04

17 LVEDD (mm) specificity sensitivity 89 % 65 LVEDD and Reverse Remodeling EACTS 15/09/04

18

19

20

21 RESULTS PRE-MVPPOST-MVP LVEDD65 mm53 mm LVESD49 mm32 mm LA43 mm35 mm MVA2.2 cm 2 Mean gradient2.8 mmHg

22 11 patients MRI pre-surgery and follow-up MRI 7 men / 4 women mean age ± SD: 53 ± 14 years mean follow-up period ± SD: 42 ± 7 months Long-Term Durability after restrictive MVP

23 PRE POST (note: MI jet)(note: restrictive ring) Long-Term Durability after restrictive MVP

24 PREPOSTp-value LAEDV (ml)87 ± 2690 ± LAESV (ml)152 ± ± LVEDV (ml)219 ± ± LVESV (ml)90 ± 4559 ± LVEF (%)36 ± 1053 ± LV Mass (g)137 ± ± Long-Term Durability after restrictive MVP

25 Conclusions RMA + CABG yield reverse remodeling Preoperative LV dimensions limit extent of reverse remodeling Additional techniques may be needed when LVEDD > 65 EACTS 15/09/04

26 Restrictive Mitral Annuloplasty in Non-ischemic Dilating Cardiomyopathy Non-ischemic Dilating Cardiomyopathy J. Braun, J.J. Bax, M.I.M. Versteegh, P.G. Voigt, E.R. Holman, R.J.M. Klautz, R.A.E. Dion Departments of Cardiothoracic Surgery and Cardiology, Leids Universitair Medisch Centrum

27 Patient Characteristics 02/02/05 July 2000 – March patients6 RMA + CorCap 23 RMA

28 Baseline echocardiography MR grade3.7 ± / 4+ : 100 % LVESD (mm)62 ± 10 LVEDD (mm)74 ± 11 02/02/05

29 Surgery mean annuloplasty ring size26 ± 2 size 24 : n = 10 TVP12 ( 52 %) TEE coaptation (mm) 8 ± 1 CPB time (min)120 ± 27 Ao-clamp (min) 70 ± 21 02/02/05

30 Results (1) POD 3: F 63 y – NYHA III – LV 73 / 63 RMA 26 postop tamponade – persisting AF IABP – CVVH - MOF Early mortality 8.6 % (n=2)

31 Results (3) Late mortality 14.2 % (n=3) 10 mo :VF – resuscitation 18 mo :collapse 27 mo :septicaemia 02/02/05

32 Results (4) Clinical follow-up ( 27 ± 13 months) NYHA3.3 ± ± I II III IV death 02/02/05

33 Results (5) Follow up17 ± 9 months MR 0.7 ± MR grade 2 1 MR grade 3 LVEDD (mm)75 ± 9 mm64 ± 10 LVESD (mm)62 ± 9 mm58 ± 13 Echocardiography 02/02/05

34 CorCap™ NVT 08/10/04

35 PATIENTS Nov 2002 – June 2005: 25 pts age (y)62.5 (34-76) males17 NYHA 3.4 EuroSCORE14 LVEF (%)22 (15-26) LUMC 06-05

36 Concomitant Procedures MVP24 TVP19 AF ablation 4 CABG 5 AVR 1 CPB (min) X clamptime (min) LUMC 06-05

37 Echocardiography LUMC Pre-opDischargeFollow-up (6 m) MR LVEDD (mm) LVESD (mm)

38 Left ventricular restoration in ischemic congestive heart failure: The Leiden Experience Klein P. 1, Versteegh M.I.M. 1, Klautz R.J.M. 1, de Weger A. 1, Tavilla G. 1, Holman E.R. 2, Bax J.J. 2, Dion R.A.E. 1 1 Department of Cardiothoracic Surgery, 2 Department of Cardiology Leids Universitair Medisch Centrum

39 Study population (I) 39 patients with ICHF 30 males, mean age 62 ± 11 years NYHA-class 3.1 ± 0.5 LVEF 20.5 ± 6.4% median interval after infarction 36 months (1-240) EuroSCORE 14 ± 13 5 patients were operated in emergency (13%) 2 pre-op IABP 1 pre-op ventilation 1 acute infarction

40 Surgical procedure according to DOR Fontan stitch sizing of residual LV using a saline-filled balloon (55 ml / m 2 BSA) elliptical shape !

41 Dor / SVR

42 Concomitant procedures CABG in 28 patients (72%) Mean number of distal anastomoses 2.4 ± 1.2 Restrictive mitral annuloplasty in 25 patients (64%) Mean ring size 26 ± 2 Tricuspid annuloplasty 10 (26%) VT-ablation 1 (3%) VSR-repair 1 (3%)

43 Mortality / morbidity Hospital mortality10,3% Post-operative complications peri-operative MI0% postoperative IABP26% bleeding needing reoperation3% CVA3% dialysis8% 1 pre-op chronic dialysis

44 Echocardiographic data Pre-operativePost-operativep-value LVEF (%)20.5 ± ± 9.8<.001 LVESD (mm)52.4 ± ± LVEDD (mm)65.5 ± ± LVESV (ml)205.6 ± ± 40.1<.001 LVEDV (ml)257.6 ± ± 45.5<.001

45 LVR and mitral valve repair Apical four chamber view before restoration

46 LVR and mitral valve repair Apical four chamber. Note the patch at the apical region and the improved contraction.

47 Results: RMA + DOR + CABG

48 Sustained left ventricular reverse remodeling, improved systolic function and unchanged diastolic function six months after surgical ventricular restoration S.A.F. Tulner, P. Steendijk, R.J.M. Klautz, J.J. Bax, P.Oemrawsingh, H.F. Verwey, M.J. Schalij, E.E. van der Wall, R.A.E. Dion Departments of Cardio-Thoracic Surgery and Cardiology Leiden University Medical Center

49 Clinical results ICU stay 6 days (1-35) Hospital stay 14 days (8-47) Mean follow-up 13 ± 10 months Late mortality 11.4% (4 patients) CHF 2 (+10mo, +1mo) Cancer 1, CVA 1 Mean NYHA at follow-up 1.1 ± 0.3

50 0I Death NYHAclassPost 0II 28III 11 IV Pre

51 Conclusions LVR for ischemic CHF with mitral insufficiency can be performed with acceptable mortality. At follow-up there is a sustained improvement of LVEF and reduction of LV volumes with a tendency towards reverse remodeling of the remote myocardium.

52 The "Leiden Algorithm" Preop LVEDD < 65:RMA > 65 < 80:RMA + CorCap RMA + "Dor" > 80:HTX SVR (+ RMA)

53

54 Reversible cause? No Correction Recovery Follow Up NON-ISCHEMIC (medication+ lifestyle) No complete recovery RESYNCHRONIZATION? Significant Valve disease? Indication SVR? Valve surgery + SVR Valve surgery ± CorCap Yes No Indication SVR? Yes No INVASIVE SURGERYREVASCULARISATION/SURGERY No ISCHEMIC Ischemia and/or viability? AP and significant CAD? CABG + valve-surgery Significant Valve disease? CABG + SVR/Dor + valve surgery Indication LV- reconstruction? SVR/Dor Indication LV- reconstruction? Valve surgery + SVR/Dor Indication SVR/Dor? Significant Valve disease? CABG + SVR/Dor PCI or CABG Yes No Yes No Valve surgery (± CorCap) No Yes Indication SVR? Yes No FOLLOW UP Yes MISSION! HF

55 INVASIVE MISSION! HF REVASCULARISATION/SURGERY ISCHEMIC Ischemia and/or viability? AP and significant CAD? CABG + valve-surgery Significant Valve disease? CABG + SVR/Dor + valve surgery Indication LV- reconstruction? SVR/Dor Indication LV- reconstruction? Valve surgery + SVR/Dor Indication SVR/Dor? Significant Valve disease? CABG + SVR/Dor PCI or CABG Yes No Yes No Valve surgery (± CorCap) No Yes Indication SVR? Yes No FOLLOW UP Yes RESYNCHRONIZATION?

56 Reversible cause? No CorrectionRecovery Follow Up NON-ISCHEMIC (medication+ lifestyle) No complete recovery RESYNCHRONIZATION? Significant Valve disease? Indication SVR? Valve surgery + SVR Valve surgery ± CorCap Yes No Indication SVR? Yes No INVASIVE SURGERY No FOLLOW UP MISSION! HF

57 SCREENING & ETIOLOGY History NYHA class Examination LAB ECG X-ray Chest TTE Further analysis Chronic heart failure? No LVEF < 40% NYHA III or IV Exercise testing with VO2 max Myoview stress and rest, FDG CAG (left & right) 24 hour Holter monitoring additional LAB QOL score + 6 min. walk test Old myocardial infarction and/or  1 coronair with > 50% stenosis? Yes ISCHEMIC causeNON-ISCHEMIC cause No LAB NT-proBNP Complete blood count ESR, CRP Electrolytes, Creat, BUN Liver panel Lipid profile TSH, fT4 Glucose Yes No Yes THERAPY Further analysis

58 MISSION! HF BASIS NYHA I Continue medication(!), lower dosis diuretics NYHA II Atrial fibrillation VR > 100: Digoxine Diuretics ACE-inhibitor Βeta blocker + + Thiazide 1 dd when mild HF and clearance > 30 - start ATB in case of ACE-intolerance - c.i.: potassium > 5.5, dubbelsided renal arterystenosis - raise every 2 weeks untill (individual) maximum Persisting low potassium: start spironolacton 1 dd 12.5 mg or Inspra 1 dd 12.5 mg Loopdiuretics 1 dd Loopdiuretics 2 dd - start when no signs of decompensation - raise every 2 weeks until (individual) maximum Loopdiuretics 2 dd + Thiazide Nitrate in case of orthopnoea Consider Nitrate i.c.w. Hydralazine in case of ACE-intolerance Spironolacton 1dd 25 mg - in case of gynaecomasty: eplerenone 1 dd mg - c.i.: potassium > 5.0, Creat > if needed, consider ATB in stead of spironolacton NYHA III or IV NYHA IV Digoxin (sinusrhythm) NYHA III MEDICATION

59 MISSION! HF RESYNCHRONIZATION? Biventricular ICD FOLLOW UP EF < 30% VF or haemodynamic unstable VT ICD EF % + VT/NSVT EFO Indication HTx? Stemcell therapy? ICD When pre-operative: LVEF 40 or QRS > 120ms: - epicardial LV-lead peri- operative - post-operative biventricular ICD When pre-operative: - LVEF < 30%: ICD post-operative - LVEF > 30% + (NS)VT: EFO + ICD When surgery waitinglist is long and (biv) ICD indication: consider (biv) ICD implantation pre- operatively SL delay > 40 ms (EF < 30% + NYHA III or IV) Yes No SCD RISK ASSESSMENT

60 MISSION! HF FOLLOW UP and RE-EVALUATION Month 3 + Month 9 Week 2-3 AFTER INVASIVE PROCEDURE DOCTOR + HF nurse History, NYHA class Examination LAB ECG TTE (only Month 3 visit) HF nurse History, NYHA class Examination LAB (incl. NT-proBNP) ECG REGULAR FOLLOW UP Month 6 + Month 12 DOCTOR + HF nurse HF nurse History, NYHA class Examination LAB (incl. NT-proBNP) ECG QOL + 6 min. walk test Exercise + VO2max TTE Only month 12 visit: 24 hour holter RE-EVALUATION Every year or worsening NYHA When appropriate, re-evaluate indication for: - revascularisation - valve / LV surgery - resynchronization therapy - ICD - HTx - stemcell therapy every 3 months DOCTOR + HF nurse History, NYHA class Examination LAB (incl. NT-proBNP) ECG Exercise + VO2max TTE LUMC every year OWN CARDIOLOGIS T NYHA class III / IV NYHA class I / II History, NYHA class Examination LAB ECG DOCTOR + HF nurse History, NYHA class Examination LAB (incl. NT-proBNP) ECG TTE Exercise + VO2max QOL + 6 min. walk test Holter (CAG) ( Myoview) PRE-OP 2 weeks before surgery HF nurse History, NYHA class Examination LAB ECG RE-EVALUATION DOCTOR every 6 months History, NYHA class Examination LAB ECG

61 Acute hemodynamic effects of restrictive mitral annuloplasty in patients with end-stage heart failure S.A.F. Tulner, P. Steendijk, R.J.M. Klautz, J.J. Bax, M.I.M. Versteegh, E.E. van der Wall, R.A.E. Dion J Thorac Cardiovascular Surgery (in press) Departments of Cardio-Thoracic Surgery and Cardiology Leiden University Medical Center

62 Results: typical example of RMA

63 Control group –Unchanged systolic function –Improved active relaxation, increased diastolic chamber stiffness Restrictive Mitral Annuloplasty –No significant acute effects on global, and intrinsic systolic function –Alterations in diastolic function appear similar to the control group Conclusions


Download ppt "End-Stage Heart Failure: Surgical Options ischemia (CABG) mitralis insuf. (RMA) "Dor" aneurysmectomy Surgical Ventricular Restoration mechanical /assistance."

Similar presentations


Ads by Google